“are, as follows: - 1”

The coroner’s concerns

are, as follows: - 1. Multi-agency Risk Assessment Conference ("MARAC") I heard evidence of issues of assault, violence and intimidation. Further that the consent of the individual reporting the concerns is not always required in order to complete a MARAC referral. Whilst I recognise that the extent of the issues could have been diminished out of fam ilia I ties or for other reasons, I am concerned that that staff did not explore the issues to a greater extent with the deceased, the wider family and other agencies. 2. Assessment of substance misuse The service user had a history of substance misuse in particular cannabis and its impact on mental health was recognised. Whilst I acknowledge issues regarding service user consent and compliance, I am concerned there was no referral to substance misuse services for advice or assessment and treatment whilst an inpatient or in the community. 3. Inpatient discharge 30 May 2018 The discharge was not a coordinated discharge in line with the trust CPA policy. There was no discharge meeting, no involvement with other agencies or family, the service user was still mentally unwell, having delusional beliefs, without supported accommodation, vulnerable, moving to a new locality and without familial support I am concerned there was a lack of opportunity to involve the family or other agencies in the discharge. I am concerned that there was no direct contact or introduction to the service user from the care coordinator whilst an inpatient or before discharge to establish a relationship and trust. 4. Discharge from the Community Treatment Team on 6 Au_gust 2018 There was no pre-discharge meeting in line with trust CPA Policy involving the family, lead professionals, other agencies or a Consultant Psychiatrist for future planning. A more assertive approach to engagement may have been appropriate. I am concerned that following discharge from the Lowry ward to the community and prior to discharge from the community treatment team, the deceased was seen only four times in person by individuals from the mental health team and only once by the care coordinator. I am concerned that more intense, in person engagement was warranted and discharge from the Community Treatment Team was premature. I am concerned that the service user was not seen by a Consultant Psychiatrist at all after 30 May 2018 despite enquiring about a further appointment. 5. Appointment of a Care Coordinator I heard that in line with the trust CPA policy paragraph 12.1 "Consent must always be sought from a professional prior to them being identified as a Care Coordinator. Under no circumstances must any professional be stated as Care Coordinator without negotiation and agreement. " I am concerned that consent and agreement was not obtained from a care coordinator prior to being identified for the role of care coordinator and concerns regarding capacity were not considered. 6. FACE Risk assessment tool I am concerned that there continues to be an inconsistent approach to the assessment of risk. Various methods are still being deployed and there is a possibility of a disparity in the understanding of the risk to the service user and others. 7. Record Keeping Documentation I am concerned that entries in the RiO medical records were not made in line with Trust guidance in a timely, complete manner or at all. I am concerned that evidence of clinical assessment, care planning and the reasoning behind clinical decision making were not recorded. 8. Contact with !RT and referral to Community Treatment Team The service user contacted the service on a number of occasions and sought self-referral to the Crisis team on 19 September 2018 who assessed her as requiring a re-referral to the community team. No referral was made. I am concerned that there was a delay in the referral to the Community Treatment Team and there is no audit system to ensure referrals are made and in a timely fashion.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0150

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0